APPENDIX X [Amendment Number 5]
Exhibit
10.1
APPENDIX
X
[Amendment
Number 5]
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Agency
Code 12000
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Contract
No. C020454
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Period
4/1/07-9/30/08
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Funding
Amount for Period Based
on approved
capitation rates
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This
is
an AGREEMENT between THE STATE OF NEW YORK, acting by and through The New York
State
Department of Health, having its principal office at Corning
Tower, Room 0000,
Xxxxxx Xxxxx Xxxxx, Xxxxxx XX 00000, (hereinafter referred to as the
STATE), and WellCare
of New York,
Inc., (hereinafter
referred
to as the CONTRACTOR),
to modify Contract
Number C020454 as set forth below. The effective date of these
modifications is April 1, 2007, unless otherwise noted below.
1. Amend
Section 19.1 of the
"Table of Contents for Model Contract," to read, "Section 19.1 Maintenance
of Contractor
Performance Records, Records Evidencing Enrollment Fraud and Documentation
Concerning
Duplicate CINs."
2.
Amend
Section 3.6, "SDOH
Right to Recover Premiums." to read as follows:
3.6 SDOH
Right to Recover Premiums
The
parties acknowledge and accept that the SDOH has a right to recover premiums
paid to the Contractor for MMC Enrollees listed on the monthly Roster
who are
later determined for the entire applicable payment month, to have been
in an
institution; to have been incarcerated; to have moved out of the Contractor's
service area subject to any time remaining in the MMC Enrollee's Guaranteed
Eligibility period; or to have died. SDOH has a right to recover premiums
for
FHPlus Enrollees listed on the Roster who are determined to have been
incarcerated; to have moved out of the Contractor's service area; or
to have
died. In any event, the State may only recover premiums paid for MMC
and/or
FHPlus Enrollees listed on a Roster if it is determined by the SDOH that
the
Contractor was not at risk for provision of Benefit Package services
for any
portion of the payment period. Notwithstanding the foregoing, the SDOH
always
has the right to recover duplicate MMC or FHPlus premiums paid for persons
enrolled under more than one Client Identification Number (CIN) in the
Contractor's MMC or FHPlus product whether or not the Contractor has
made
payments to providers.
3. Amend
Section 19.1,
"Maintenance of Contractor Performance Records," to read as
follows:
19.1 Maintenance
of Contractor Performance Records, Records Evidencing Enrollment Fraud
and
Documentation Concerning Duplicate CINs
a)
The
Contractor shall maintain and shall require its subcontractors, including
its
Participating Providers, to maintain appropriate records relating to
Contractor
performance under this Agreement, including:
i)
records related to services provided to Enrollees, including a separate
Medical
Record for each Enrollee;
ii)
all
financial records and statistical data that LDSS, SDOH and any other
authorized
governmental agency may require, including books, accounts, journals,
ledgers,
and all financial records relating to capitation payments, third party
health
insurance recovery, and other revenue received, any reserves related
thereto and
expenses incurred under this Agreement;
Appendix
X
MMC/FHPlus
Contract Amendment
April
1,
2007
Page
1
iii)
all
documents concerning enrollment fraud or the fraudulent use of any
CIN;
iv)
all
documents concerning duplicate CINs;
v)
appropriate financial records to document fiscal activities and expenditures,
including records relating to the sources and application of funds and
to the
capacity of the Contractor or its subcontractors, including its Participating
Providers, if applicable, to bear the risk of potential financial
losses.
b)
The
Contractor shall maintain all
Access NY Health Care (DOH-4220), Medicaid Choice, and SDOH
enrollment applications (DOH-4097) and recertification forms completed
by the
Contractor or its subcontractors in fulfilling its responsibilities related
to
Facilitated Enrollment as set forth in Appendix P of this
Agreement.
c) The
record maintenance requirements of this Section shall survive the termination,
in whole or in part, of this Agreement.
4. Amend
Section 19.3, "Access
to Contractor Records," to read as follows:
19.3 Access
to Contractor Records
The
Contractor shall provide SDOH, the Comptroller of the State of New York,
DHHS,
the Comptroller General of the United States, and their authorized
representatives with access to all records relating to Contractor performance
under this Agreement for the purposes of examination, audit, and copying
(at
reasonable cost to the requesting party). The Contractor shall give access
to
such records on two (2) business days prior written notice, during normal
business hours, unless otherwise provided or permitted by applicable
laws,
rules, or regulations. Notwithstanding the foregoing, when records are
sought in
connection with a "fraud" or "abuse" investigation, as defined respectively
in
10 NYCRR §98.1.21 (a) (1) and (a) (2), all costs associated with production and
reproduction shall be the responsibility of the Contractor.
5.
Xxxxx
X.X 1. a) iii) B) of
Appendix C, "New York State Department of Health Requirements for the
Provision
of Family Planning and Reproductive Health," to read as
follows:
B)
For
FHPlus Enrollees - The Contractor, if it includes such services in its
Benefit
Package is responsible for covering contraceptives, including emergency
contraceptives, provided by a Participating pharmacy or a participating
provider
or clinic. The Contractor is responsible for prescription contraceptives
consistent with the pharmacy benefit package as described in Appendix
K, as well
as for contraceptives obtained and administered by a provider in an office
or
clinic setting. When the Contractor does not provide Family Planning
and
Reproductive Health Services, the Designated Third Party Contractor that
covers
such services for FHPlus Enrollees is responsible for contraceptives,
including
emergency contraceptives, provided by a Participating pharmacy or a
participating provider or clinic. The Designated Third Party Contractor
is
responsible for prescription contraceptives consistent with the pharmacy
benefit
package as described in Appendix K, as well as for contraceptives obtained
and
administered by a provider in an office or clinic setting. The Contractor
or the
Designated Third Party Contractor must cover at least one of every type
of the
following methods of contraception:
I) Oral
II) Oral,
emergency
III)
Injectable
Appendix
X
MMC/FHPIus
Contract Amendment
April
1,
2007
Page
2
IV)
Transdermal
V)
Intravaginal
VI)
Intravaginal, systemic
VII)
Implantable
6. The
attached Appendix H,
"New York State Department of Health Requirements for the Processing
of Enrollments
and Disenrollments in the MMC and FHPlus Programs," is substituted for
the period beginning
April 1, 2007.
7. The
attached Appendix L,
"Approved Capitation Payment Rates," is substituted for the period beginning
April 1,
2007.
All
other
provisions of said AGREEMENT shall remain in full force and
effect.
Appendix
X
MMC/FHPlus
Contract Amendment
April
1,
2007
Page
3
IN
WITNESS WHEREOF, the parties hereto have executed or approved this AGREEMENT
as
of the dates appearing under their signatures.
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CONTRACTOR
SIGNATURE
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STATE
AGENCY SIGNATURE
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By:
/s/ Xxxx
X. Xxxxx
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By: /s/ Xxxxxxxxx
Xxxxx
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Xxxx
X. Xxxxx
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Xxxxxxxxx
Xxxxx
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Title:
President and CEO
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Title:
Deputy Director, DMC & PE
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Date:
10/5/07
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Date:
11/2/07
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State
Agency Certification:
In
addition to the acceptance of this contract, I also certify that
original
copies of this signature page will be attached to all other exact
copies
of this contract.
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STATE
OF
FLORIDA
County
of
Hillsborough
On
this
5th
day of October, 2007, before me personally appeared Xxxx X. Xxxxx, to
me known,
who being by me duly sworn, did depose and say that he/she resides at
Tampa,
Florida, that he/she is the President & CEO of WellCare of New York, Inc.,
the corporation described herein which executed the foregoing instrument;
and
that he/she signed his/her name hereto by order of the board of directors
of
said corporation.
/s/ Xxxx
X. Xxxxx
(Notary)
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Approved:
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Approved
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ATTORNEY
GENERAL
(XXXXX)
APPROVED
AS TO FORM NYS ATTORNEY
GENERAL
NOV
23 2007
XXXXXXXX
X. XXXX
ASSOCIATE
ATTORNEY
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Xxxxxx
X. XxXxxxxx
STATE
COMPTROLLER
(STAMP)
APPROVED
DEPT.
OF AUDIT &
CONTROL
DEC
13 2007
Illegible
FOR
THE STATE
COMPTROLLER
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|
Title:
|
Title:
|
|
Date:
|
Date:
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Appendix
X
MMC/FHPlus
Contract Amendment
April
1,
2007
Page
4
APPENDIX
H
New
York
State Department of Health Requirements
for
the
Processing of Enrollments and Disenrollments
in
the
MMC and FHPlus Programs
APPENDIX
H
April
1,
2007
H-l
SDOH
Requirements
for
the Processing of Enrollments and Disenrollments
in
the MMC and FHPlus Programs
1. General
The
Contractor's Enrollment and Disenrollment procedures shall be consistent
with
these requirements, except that to allow LDSS and the Contractor flexibility
in
developing processes that will meet the needs of both parties, SDOH,
upon
receipt of a written request from either the LDSS or the Contractor,
may allow
modifications to timeframes and some procedures. Where an Enrollment
Broker
exists, the Enrollment Broker will be responsible for some or all of
the LDSS
responsibilities as set forth in the Enrollment Broker
Contract.
2.
Enrollment
a)
SDOH
Responsibilities:
i)
The
SDOH is responsible for monitoring LDSS program activities and providing
technical assistance to the LDSS and the Contractor to ensure compliance
with
the State's policies and procedures.
ii)
SDOH
reviews and approves proposed Enrollment materials prior to the Contractor
publishing and disseminating or otherwise using the
materials.
b)
LDSS
Responsibilities:
i) The
LDSS has the primary responsibility for the Enrollment
process.
ii)
Each
LDSS determines Medicaid and FHPlus eligibility. To the extent practicable,
the
LDSS will follow up with Enrollees when the Contractor provides documentation
of
any change in status which may affect the Enrollee's Medicaid, FHPlus,
or MMC
eligibility.
iii)
The
LDSS is responsible for coordinating the Medicaid and FHPlus application
and
Enrollment processes.
iv)
The
LDSS is responsible for providing pre-enrollment information to Eligible
Persons, consistent with Sections 364-j(4)(e)(iv) and 369-ee of the SSL,
and the
training of persons providing Enrollment counseling to Eligible
Persons.
v)
The
LDSS is responsible for informing Eligible Persons of the availability
of MCOs
and HIV SNPs offering MMC and/or FHPlus products and the scope of services
covered by each.
APPENDIX
H
April
1,
2007
H-2
vi)
The
LDSS is responsible for informing Eligible Persons of the right to confidential
face-to-face Enrollment counseling and will make confidential face-to-face
sessions available upon request.
vii) The
LDSS is responsible for instructing Eligible Persons to verify with the
medical
services providers they prefer, or have an existing relationship with,
that such
medical services providers are Participating Providers of the selected
MCO and
are available to serve the Enrollee. The LDSS includes such instructions
to
Eligible Persons in its written materials related to
Enrollment.
viii)
For
Enrollments made during face-to-face counseling, if the Prospective Enrollee
has
a preference for particular medical services providers, Enrollment counselors
shall verify with the medical services providers that such medical services
providers whom the Prospective Enrollee prefers are Participating Providers
of
the selected MCO and are available to serve the Prospective
Enrollee.
ix)
The
LDSS is responsible for the timely processing of managed care Enrollment
applications, Exemptions, and Exclusions.
x)
The
LDSS is responsible for determining the status of Enrollment applications.
Applications will be enrolled, pended or denied. The LDSS will notify
the
Contractor of the denial of any Enrollment applications that the Contractor
assisted in completing and submitting to the LDSS under the circumstances
described in 2(c)(i) of this Appendix.
xi)
The
LDSS is responsible for determining the Exemption and Exclusion status
of
individuals determined to be eligible for Medicaid under Title 11 of
the
SSL.
A)
Exempt
means an individual eligible for Medicaid under Title 11 of the SSL determined
by the LDSS or the SDOH to be in a category of persons, as specified
in Section
364-j of the SSL and/or New York State's Operational Protocol for the
Partnership Plan, that are not required to participate in the MMC Program;
however, individuals designated as Exempt may elect to voluntarily
enroll.
B)
Excluded means an individual eligible for Medicaid under Title 11 of
the SSL
determined by the LDSS or the SDOH to be in a category of persons, as
specified
in Section 364-j of the SSL and/or New York State's Operational Protocol
for the
Partnership Plan, that are precluded from participating in the MMC
Program.
xii)
Individuals eligible for Medicaid under Title 11 of the SSL in the following
categories will be eligible for Enrollment in the Contractor's MMC product
at
the LDSS's option, as indicated in Schedule 2 of Appendix M.
A)
Xxxxxx
care children in the direct care of LDSS;
APPENDIX
H
April
1,
2007
H-3
B)
Homeless persons living in shelters outside of New York City.
xiii)
The
LDSS is responsible for entering individual Enrollment form data and
transmitting that data to the State's Prepaid Capitation Plan (PCP) Subsystem.
The transfer of Enrollment information may be accomplished by any of
the
following:
A) LDSS
directly enters data into PCP Subsystem; or
B)
LDSS
or Contractor submits a tape to the State, to be edited and entered into
PCP
Subsystem; or
C)
LDSS
electronically transfers data, via a dedicated line or Medicaid Eligibility
Verification System (MEVS) to the PCP Subsystem.
xiv)
The
LDSS is responsible for sending the following required notices to Eligible
Persons:
A)
For
mandatory MMC program only - Initial Notification Letter: This letter
informs
Eligible Persons about the mandatory MMC program and the timeframes for
choosing
a MCO offering a MMC product. Included with the letter are managed care
brochures, an Enrollment form, and information on their rights and
responsibilities under this program, including the option for HIV/AIDS
infected
individuals who are categorically exempt from the mainstream MMC program
to
enroll in an HIV SNP on a voluntary basis in LDSS jurisdictions where
HIV SNPs
exist.
B)
For
mandatory MMC program only - Reminder Letter: A letter to all Eligible
Persons
in a mandatory category who have not responded by submitting a completed
Enrollment form within thirty (30) days of being sent or given an Enrollment
packet.
C)
For
MMC program - Enrollment Confirmation Notice for MMC Enrollees: This
notice
indicates the Effective Date of Enrollment, the name of the MCO and all
individuals who are being enrolled. This notice should also be used for
case
additions and re-enrollments into the same MCO. There is no requirement
that an
Enrollment Confirmation Notice be sent to FHPlus Enrollees.
D)
Notice
of Denial of Enrollment: This notice is used when an individual has been
determined by LDSS to be ineligible for Enrollment into the MMC or FHPlus
program. This notice must include fair hearing rights. This notice is
not
required when Medicaid or FHPlus eligibility is being denied (or
closed).
E)
For
MMC program only - Exemption Request Forms: Exemption forms areprovided
to MMC Eligible Persons upon request if they wish to apply for
an
APPENDIX
H
April
1,
2007
H-4
Exemption. Individuals
precoded on the system as meeting Exemption or Exclusion criteria do
not need to
complete an Exemption request form. This notice is required for mandatory
MMC
Eligible Persons.
F)
For
MMC program only - Exemption and Exclusion Request Approval or Denial:
This
notice is designed to inform a recipient who applied for an exemption
or who
failed to provide documentation of exclusion criteria when requested
by the LDSS
of the LDSS’s disposition of the request, including the right to a
fair hearing if the request for exemption or exclusion is denied. This
notice is
required for voluntary and mandatory MMC Eligible Persons.
c) Contractor
Responsibilities:
i)
To the
extent permitted by law and regulation, the Contractor may accept Enrollment
forms from Potential Enrollees for the MMC program, provided that the
appropriate education has been provided to the Potential Enrollee by
the LDSS
pursuant to Section 2(b) of this Appendix. In those instances, the Contractor
will submit resulting Enrollments to the LDSS, within a maximum of five
(5)
business days from the day the Enrollment is received by the Contractor
(unless
otherwise agreed to by SDOH and LDSS).
ii)
The
Contractor must notify new MMC and FHPlus Enrollees of their Effective
Date of
Enrollment. In the event that the actual Effective Date of Enrollment
is
different from that previously given to the Enrollee, the Contractor
must notify
the Enrollee of the actual date of Enrollment. This may be accomplished
through
a Welcome Letter. To the extent practicable, such notification must precede
the
Effective Date of Enrollment.
iii)
The
Contractor must notify the LDSS within five (5) business days of such
information becoming blown to the Contractor of any Medicaid or FHPlus
Enrollees
whose eligibility for those programs was established based on false information
contained in applications completed by the Contractor or its subcontractors
in
fulfilling its responsibilities related to Facilitated Enrollment as
set forth
in Appendix P of this Agreement. Such information may include, but is
not
limited to, household income and/or resources (as defined in Subpart
360-4 of 18
NYCRR), household size, or address. The foregoing responsibility supplements
those set forth in Sections 23.1 and 23.2 of this Agreement.
iv)
The
Contractor must report any changes that affect or may affect the eligibility
status of its enrolled members to the LDSS within five (5) business days
of such
information becoming known to the Contractor. This includes, but is not
limited
to, address changes, verification of pregnancy, incarceration, third
party
insurance, etc.
APPENDIX
H
April
1,
2007
H-5
v)
The
Contractor, within five (5) business days of identifying cases where
a person
may be enrolled in the Contractor's MMC or FHPlus product under more
than one
CIN, must convey that information in writing to the LDSS.
vi)
The
Contractor shall advise Prospective Enrollees, in written materials related
to
Enrollment, to verify with the medical services providers they prefer,
or have
an existing relationship with, that such medical services providers are
Participating Providers of the selected MCO and are available to serve
the
Prospective Enrollee.
vii)The
Contractor shall accept all Enrollments as ordered by the Office of Temporary
and Disability Assistance's Office of Administrative Hearings due to
fair
hearing requests or decisions.
3. Newborn
Enrollments
a)
The
Contractor agrees to enroll and provide coverage for eligible newborn
children
effective from the time of birth.
b)
SDOH
Responsibilities:
i)
The
SDOH will update WMS with information on the newborn received from hospitals,
consistent with the requirements of Section 366-g of the SSL as amended
by
Chapter 412 of the Laws of1999.
ii)
Upon
notification of the birth by the hospital or birthing center, the SDOH
will
update WMS with the demographic data for the newborn and enroll the newborn
in
the mother's MCO if the newborn is not already enrolled, the mother's
MCO offers
a MMC product, and the newborn is not identified as SSI or SSI-related
and
therefore Excluded from the MMC Program pursuant to Section 2(b)(xi)
of this
Appendix. The newborn will be retroactively enrolled back to the first
(1st)
day of
the month of birth. Based on the transaction date of the Enrollment of
the
newborn on the PCP subsystem, the newborn will appear on either the next
month's
Roster or the subsequent month's Roster. On Rosters for upstate and NYC,
the
"PCP Effective From Date" will indicate the first day of the month of
birth, as
described in 01 OMM/ADM 5 "Automatic Medicaid Enrollment for Newborns."
If the
newborn's Enrollment is not completed by this process, the LDSS is responsible
for Enrollment (see (c)(iv) below).
c)
LDSS
Responsibilities:
i)
Grant
Medicaid eligibility for newborns for one (1) year if born to a woman
eligible
for and receiving Medicaid or FHPlus on the date of the newborn's
birth.
ii)
The
LDSS is responsible for adding eligible unborns to all WMS cases that
include a
pregnant woman as soon as the pregnancy is medically
verified.
APPENDIX
H
April
1,
2007
H-6
iii)
In
the event that the LDSS learns of an Enrollee's pregnancy prior to the
Contractor, the LDSS is responsible for establishing Medicaid eligibility
and
enrolling the unborn in the Contractor's MMC product. If the Contractor
does not
offer a MMC product, the pregnant woman will be asked to select a MCO
offering a
MMC product for the unborn. If a MCO offering a MMC product is unavailable,
or
if Enrollment is voluntary in the LDSS jurisdiction and an MCO is not
chosen by
the mother, the newborn will be eligible for Medicaid fee-for-service
coverage,
and such information will be entered on the WMS.
iv)
The
LDSS is responsible for newborn Enrollment if enrollment is not successfully
completed under the "SDOH Responsibilities" process as outlined in 2(b)(ii)
above.
Contractor
Responsibilities:
i)
The
Contractor must notify the LDSS in writing of any Enrollee that is pregnant
within thirty (30) days of knowledge of the pregnancy. Notifications
should be
transmitted to the LDSS at least monthly. The notifications should contain
the
pregnant woman's name, Client ID Number (CIN), and the expected date
of
confinement (EDC).
ii)
The
Contractor must send verifications of infant's demographic data to the
LDSS,
within five (5) days after knowledge of the birth. The demographic data
must
include: the mother's name and CIN, the newborn's name and CIN (if newborn
has a
CIN), sex and the date of birth.
iii)
In
districts that use an Enrollment Broker, the Contractor shall not submit
electronic Enrollments of newborns to the Enrollment Broker, because
this will
interfere with the retroactive Enrollment of the newborn back to the
first
(1st)
day of
the month of birth. For newborns whose mothers are not enrolled in the
Contractor's MMC or FHPlus product and who were not pre-enrolled into
the
Contractor's MMC product as unborns, the Contractor may submit electronic
Enrollment of the newborns to the Enrollment Broker. In such cases, the
Effective Date of Enrollment will be prospective.
iv)
In
voluntary MMC counties, the Contractor will accept Enrollment applications
for
unborns if that is the mothers' intent, even if the mothers are not and/or
will
not be enrolled in the Contractor's MMC or FHPlus product. In all counties,
when
a mother is ineligible for Enrollment or chooses not to enroll, the Contractor
will accept Enrollment applications for pre-enrollment of unborns who
are
eligible.
v)
The
Contractor is responsible for provision of services to a newborn and
payment of
the hospital or birthing center bill if the mother is an Enrollee at
the time of
the newborn's birth, even if the newborn is not yet on the Roster, unless
the
Contractor does not offer a MMC product in the mother's county of
fiscal
APPENDIX
H
April
1,
2007
H-7
responsibility
or the newborn is Excluded from the MMC Program pursuant to Section 2(b)(xi)
of
this Appendix.
vi)
Within fourteen (14) days of the date on which the Contractor becomes
aware of
the birth, the Contractor will issue a letter, informing parent(s) about
the
newborn's Enrollment and how to access care, or a member identification
card.
vii)
In
those cases in which the Contractor is aware of the pregnancy, the Contractor
will ensure that enrolled pregnant women select a PCP for their infants
prior to
birth.
viii)The
Contractor will ensure that the newborn is linked with a PCP prior to
discharge
from the hospital or birthing center, in those instances in which the
Contractor
has received appropriate notification of birth prior to
discharge.
4. Auto-Assignment
Process (Applies to Mandatory MMC Program Only):
a)
This
section only applies to a LDSS where CMS has given approval and the LDSS
has
begun mandatory Enrollment into the Medicaid Managed Care Program. The
details
of the auto-assignment process are contained in Section 12 of New York
State's
Operational Protocol for the Partnership Plan.
b)
SDOH
Responsibilities:
i)
The
SDOH, LDSS or Enrollment Broker will assign MMC Eligible Persons not
pre-coded
in WMS as Exempt or Excluded, who have not chosen a MCO offering a MMC
product
in the required time period, to a MCO offering a MMC product using an
algorithm
as specified in §364-j(4)(d) of the SSL.
ii)
SDOH
will ensure the auto-assignment process automatically updates the PCP
Subsystem,
and will notify MCOs offering MMC products of auto-assigned individuals
electronically.
iii)
SDOH
will notify the LDSS electronically on a daily basis of those individuals
for
whom SDOH has selected a MCO offering a MMC product through the Automated
PCP
Update Report. Note: This does not apply in Local Districts that utilize
an
Enrollment Broker.
c)
LDSS
Responsibilities:
i)
The
LDSS is responsible for tracking an individual's choice
period.
ii)
As
with Eligible Persons who voluntarily choose a MCO's MMC product, the
LDSS is
responsible for providing notification to assigned individuals regarding
their
Enrollment status as specified in Section 2 of this Appendix.
d)
Contractor Responsibilities:
APPENDIX
H
April
1,
2007
H-8
i) The
Contractor is responsible for providing notification to assigned
individualsregarding
their Enrollment status as specified in Section 2 of this
Appendix.
5.
Roster Reconciliation:
a) All
Enrollments are effective the first of the month.
b)
SDOH
Responsibilities:
i)
The
SDOH maintains both the PCP subsystem Enrollment files and the WMS eligibility
files, using data entered by the LDSS. SDOH uses data contained in both
these
files to generate the Roster.
A)
SDOH
shall send the Contractor and LDSS monthly (according to a schedule established
by SDOH), a complete list of all Enrollees for which the Contractor is
expected
to assume medical risk beginning on the 1st
of the
following month (First Monthly Roster). Notification to the Contractor
and LDSS
will be accomplished via paper transmission, magnetic media, or the
HPN.
B)
SDOH
shall send the Contractor and LDSS monthly, at the time of the first
monthly
roster production, a Disenrollment Report listing those Enrollees from
the
previous month's roster who were disenrolled, transferred to another
MCO, or
whose Enrollments were deleted from the file. Notification to the Contractor
and
LDSS will be accomplished via paper transmission, magnetic media, or
the
HPN.
C)
The
SDOH shall also forward an error report as necessary to the Contractor
and
LDSS.
D)
On the
first (1st)
weekend after the first (1st)
day of
the month following the generation of the first (1st)
Roster, SDOH shall send the Contractor and LDSS a second Roster which
contains
any additional Enrollees that the LDSS has added for Enrollment for the
current
month. The SDOH will also include any additions to the error report that
have
occurred since the initial error report was generated.
c)
LDSS
Responsibilities:
i)
The
LDSS is responsible for notifying the Contractor electronically or in
writing of
changes in the Roster and error report, no later than the end of the
month.
(Note: To the extent practicable the date specified must allow for timely
notice
to Enrollees regarding their Enrollment status. The Contractor and the
LDSS may
develop protocols for the purpose of resolving Roster discrepancies that
remain
unresolved beyond the end of the month.)
APPENDIX
H
April
1,
2007
H-9
ii)
Enrollment and eligibility issues are reconciled by the LDSS to the extent
possible, through manual adjustments to the PCP subsystem Enrollment
and WMS
eligibility files, if appropriate.
d) Contractor
Responsibilities:
i) The
Contractor is at risk for providing Benefit Package services for those
Enrollees
listed on the 1st and 2nd Rosters for the month in which the 2nd Roster
is
generated. Contractor is not at risk for providing
services to Enrollees who appear on the monthly Disenrollment
report.
ii)
The
Contractor must submit claims to the State's Fiscal Agent for all Eligible
Persons that are on the 1st
and
2nd
Rosters, adjusted to add Eligible Persons enrolled by the LDSS after
Roster
production and to remove individuals disenrolled by LDSS after Roster
production
(as notified to the Contractor). In the cases of retroactive Disenrollments,
the
Contractor is responsible for submitting an adjustment to void any previously
paid premiums for the period of retroactive Disenrollment, where the
Contractor
was not at risk for the provision of Benefit Package services. Payment
of
subcapitation does not constitute "provision of Benefit Package
services."
6. Disenrollment:
a) LDSS
Responsibilities:
i)
The
LDSS is responsible for accepting requests for Disenrollment directly
from
Enrollees and may not require Enrollees to approach the Contractor for
a
Disenrollment form. Where an LDSS is authorized to mandate Enrollment,
all
requests for Disenrollment must be directed to the LDSS or the Enrollment
Broker. The LDSS and the Enrollment Broker must utilize the State-approved
Disenrollment forms.
ii)
Enrollees may initiate a request for an expedited Disenrollment to the
LDSS. The
LDSS will expedite the Disenrollment process in those cases where an
Enrollee's
request for Disenrollment involves an urgent medical need, a complaint
of
nonconsensual Enrollment or, in local districts where homeless individuals
are exempt, homeless individuals in the shelter system. If approved,
the LDSS
will manually process the Disenrollment through the PCP Subsystem. MMC
Enrollees
who request to be disenrolled from managed care based on their documented
HIV,
ESRD, or SPMI/SED status are categorically eligible for an expedited
Disenrollment on the basis of urgent medical need.
iii)
The
LDSS is responsible for processing routine Disenrollment requests to
take effect
on the first (lst)
day of
the following month if the request is made before the fifteenth (15th)
day of
the month. In no event shall the Effective Date of Disenrollment be later
than
the first (1st)
day of
the second month after the month in which an Enrollee requests a
Disenrollment.
APPENDIX
H
April
1,
2007
H-10
iv)
The
LDSS is responsible for disenrolling Enrollees automatically upon death
or loss
of Medicaid or FHPlus eligibility. All such Disenrollments will be effective
at
the end of the month in which the death or loss of eligibility occurs
or at the
end of the last month of Guaranteed Eligibility, where
applicable.
v) The
LDSS is responsible for informing Enrollees of their right to change
Contractors if there is more than one available including any applicable
Lock-In
restrictions. Enrollees subject to Lock-In may disenroll after the grace
period
for Good Cause as defined below. The LDSS is responsible for determining
if the
Enrollee has Good Cause and processing the Disenrollment request in accordance
with the procedures outlined in this Appendix. The LDSS is responsible
for
providing Enrollees with notice of their right to request a fair hearing
if
their Disenrollment request is denied. Such notice must include the reason(s)
for the denial. An Enrollee has Good Cause to disenroll if:
A)
The
Contractor has failed to furnish accessible and appropriate medical care
services
or supplies to which the Enrollee is entitled under the terms, of the
contract
under which the Contractor has agreed to provide services.
This
includes,
but is not limited to the failure to:
I)
provide primary care services;
II)
arrange for in-patient care, consultation with specialists, or laboratory
and
radiological services when reasonably necessary;
III)
arrange for consultation appointments;
IV)
coordinate and interpret any consultation findings with emphasis on continuity
of medical care;
V)
arrange for services with qualified licensed or certified
providers;
VI)
coordinate the Enrollee's overall medical care such as periodic immunizations
and diagnosis and treatment of any illness or injury; or
B)
The
Contractor cannot make a Primary Care Provider available to the Enrollee
within
the time and distance standards prescribed by SDOH; or
C)
The
Contractor fails to adhere to the standards prescribed by SDOH and such
failure
negatively and specifically impacts the Enrollee; or
D)
The
Enrollee moves his/her residence out of the Contractor's service area
or to a
county where the Contractor does not offer the product the Enrollee is
eligible
for; or
E)
The
Enrollee meets the criteria for an Exemption or Exclusion as set forth
in2(b)(xi)
of this Appendix; or
F)
It is
determined by the LDSS, the SDOH. or its agent that the Enrollment was
not
consensual; or
APPENDIX
H
April
1,
2007
H-ll
G)
The
Enrollee, the Contractor and the LDSS agree that a change of MCOs would
be in
the best interest of the Enrollee; or
H)
The
Contractor is a primary care partial capitation provider that does not
have a
utilization review process in accordance with Title I of Article 4.9
of the PHL
and the Enrollee requests Enrollment in an MCO that has such a utilization
review process; or
I)
The
Contractor has elected not to cover the Benefit Package service that
an Enrollee
seeks and the service is offered by one or more other MCOs in the Enrollee's
county of fiscal responsibility; or
J) The
Enrollee's medical condition requires related services to be performed
at the
same time but all such related services cannot be arranged by the Contractor
because the Contractor has elected not to cover one of the services the
Enrollee
seeks, and the Enrollee's Primary Care Provider or another provider determines
that receiving the services separately would subject the Enrollee to
unnecessary
risk; or
K)
An
FHPlus Enrollee is pregnant.
vi)
An
Enrollee subject to Lock-In may initiate Disenrollment for Good Cause
by filing
an oral or written request with the LDSS.
vii)
The
LDSS is responsible for promptly disenrolling an MMC Enrollee whose MMC
eligibility or health status changes such that he/she is deemed by the
LDSS to
meet the Exclusion criteria. The LDSS will provide the MMC Enrollee with
a
notice of his or her right to request a fair hearing.
viii)
In
instances where an MMC Enrollee requests Disenrollment due to MMC Exclusion,
the
LDSS must notify the MMC Enrollee of the approval or denial of
exclusion/Disenrollment status, including fair hearing rights if Disenrollment
is denied.
ix)
The
LDSS is responsible for ensuring that retroactive Disenrollments are
used only
when absolutely necessary. Circumstances warranting a retroactive Disenrollment
are rare and include when an Enrollee is determined to have been
non-consensually enrolled in a MCO; he or she enters or resides in a
residential
institution under circumstances which render the individual Excluded
from the
MMC program; is incarcerated; is an SSI infant less than six (6) months
of age;
is simultaneously in receipt of comprehensive health care coverage from
an MCO
and is enrolled in either the MMC or FHPlus product of the same MCO;
or he or
she has died - as long as the Contractor was not at risk for provision
of
Benefit Package services for any portion of the retroactive period. Payment
of
subcapitation does not constitute "provision of Benefit Package services."
Notwithstanding the foregoing, the SDOH always has the right to recover
duplicate MMC or FHPlus premiums paid for persons enrolled under more
than
APPENDIX
H
April
1,
2007
H-12
one
Client Identification Number (CIN) in the Contractor's MMC or FHPlus
product
whether or not the Contractor has made payments to providers.
x)
The
SDOH may recover premiums paid for Medicaid or FHPlus Enrollees whose
eligibility for those programs was based on false information, when such
false
information was provided as a result of intentional actions or failures
to act
on the part of an employee of the Contractor; and the Contractor shall
have no
right of recourse against the Enrollee or a providers of service for
the cost of
services provided to the Enrollee for the period covered by such
premiums.
xi)
The
LDSS is responsible for notifying the Contractor of the retroactive
Disenrollment prior to the action. The LDSS is responsible for finding
out if
the Contractor has made payments to providers on behalf of the Enrollee
prior to
Disenrollment. After this information is obtained, the LDSS and Contractor
will
agree on a retroactive Disenrollment or prospective Disenrollment date.
In all
cases of retroactive Disenrollment, including Disenrollments effective
the first
day of the current month, the LDSS is responsible for sending notice
to the
Contractor at the time of Disenrollment, of the Contractor's responsibility
to
submit to the SDOH's Fiscal Agent voided premium claims within thirty
(30)
business days of notification from the LDSS for any full months of retroactive
Disenrollment where the Contractor was not at risk for the provision
of Benefit
Package services during the month. Notwithstanding the foregoing, the
SDOH
always has the right to recover duplicate MMC or FHPlus premiums paid
for
persons enrolled under more than one Client Identification Number (CIN)
in the
Contractor's MMC or FHPlus product whether or not the Contractor has
made
payments to providers. Failure by the LDSS to notify the Contractor does
not
affect the right of the SDOH to recover the premium payment as authorized
by
Section 3.6 of this Agreement or for the State Attorney General to bring
legal
action to recover any overpayment.
APPENDIX
H
April
1,
2007
H-13
xii)
Generally the effective dates of Disenrollment are
prospective. Effective dates for other than routine
Disenrollments are described below:
|
Reason
for Disenrollment
|
Effective
Date of Disenrollment
|
|
|
A)
Infants weighing less than 1200 grams at birth and other infants
under six
(6) months of age who meet the criteria for the SSI or SSI
re1ated
category
|
First
Day of the month of birth of the month of onset of disability,
whichever
is later.
|
|
|
B)
Death of Enrollee
|
First
day of the month after death
|
|
|
C)
Incarceration
|
First
day of the month of incarceration (note- Contractor is at risk
for covered
services only to the date of incarceration and is entitled to
the
capitation payment for the month of incarceration)
|
|
|
D)
Medicaid Managed Care Enrollee entered or stayed in a residential
institution under circumstances which rendered the individual
excluded
from managed care, or is in receipt of waivered services through
the Long
Term Home Health Care Program (LTHHCP), including when an Enrollee
is
admitted to a hospital that 1) is certified by Medicare as
a long-term
care hospital and 2) has an average length of stay for all
patients
greater than ninety-five (95) days as reported in the Statewide
Planning
and Research Cooperative System (SPARCS) Annual Report 2002.
|
First
day of the month of entry or first day of the month of classification
of
the stay as permanent subsequent to entry (note-Contractor
is at risk for
covered services only to the date of entry or classification
of the stay
as permanent subsequent to entry, and is entitled to the capitation
payment for the month of entry or classification of the stay
as permanent
subsequent to entry)
|
|
|
E)
Individual's effective date of Enrollment orautoassignment
into a MMC product occurred
whilemeeting
institutional criteria in (D) above
|
Effective
Date of Enrollment in the Contractor's Plan
|
|
|
F)
Non-consensual Enrollment
|
Retroactive
to the first day of the month of the request
|
|
|
G)
Enrollee moved outside of the District/County of Fiscal
Responsibility
|
First
day of the month after the update of the system with the new
address1
|
|
|
H)
Urgent medical need
|
First
day of the next month after determination except where medical
need
requires an earlier Disenrollment
|
|
|
I) Homeless
Enrollees in Medicaid Managed Care residing in the shelter
system in NYC
or in other districts where homeless individuals are exempt
|
Retroactive
to the first day of the month of the request
|
|
|
J)
Individual is simultaneously in receipt of comprehensive health
care
coverage from an MCO and is Enrolled in either the MMC or FHPIus
product
of the same MCO
|
First
day of the month after simultaneous coverage
began
|
|
|
K)
An Enrollee with more than one Client Identification Number
(CIN) is
enrolled in an MCO's MMC or FHPIus product under more than
one of the
CINs
|
First
day of the month the duplicate Enrollment
began
|
1
In
counties outside of New York City, LDSSs should work together to ensure
continuity of care through the Contractor if the Contractor's service
area
includes the county to which the Enrollee has moved and the Enrollee,
with
continuous eligibility, wishes to stay enrolled in the Contractor's MMC
or
FHPIus product. In New York City, Enrollees, not in guaranteed status,
who move
out of the Contractor's Service Area but not outside of the City of New
York
(e.g., move from one borough to another), will not be involuntarily disenrolled,
but must request a Disenrollment or transfer. These Disenrollments will
be
performed on a routine basis unless there is an urgent medical need to
expedite
the Disenrollment.
APPENDIX
H
April
1,
2007
H-14
xiii)
The
LDSS is responsible for rendering a determination and responding within
thirty
(30) days of the receipt of a fully documented request for Disenrollment,
except
for Contractor-initiated Disenrollments where the LDSS decision must
be made
within fifteen (15) days. The LDSS, to the extent possible, is responsible
for
processing an expedited Disenrollment within two (2) business days of
its
determination that an expedited Disenrollment is warranted.
xiv)
The
Contractor must respond timely to LDSS inquiries regarding Good
Cause Disenrollment requests to enable the LDSS to make a
determination within thirty (30) days of the receipt of the request from
the
Enrollee.
xv)
The
LDSS is responsible for sending the following notices to Enrollees regarding
their Disenrollment status. Where practicable, the process will allow
for timely
notification to Enrollees unless there is Good Cause to disenroll more
expeditiously.
A)
Notice
of Disenrollment: This notice will advise the Enrollee of the LDSS's
determination regarding an Enrollee-initiated, LDSS-initiated or
Contractor-initiated Disenrollment and will include the Effective Date
of
Disenrollment. In cases where the Enrollee is being involuntarily disenrolled,
the notice must contain fair hearing rights.
B)
When
the LDSS denies any Enrollee's request for Disenrollment pursuant to
Section 8
of this Agreement, the LDSS is responsible for informing the Enrollee
in
writing, explaining the reason for the denial, stating the facts upon
which the
denial is based, citing the statutory and regulatory authority and advising
the
Enrollee of his/her right to a fair hearing pursuant to 18NYCRR Part
358.
C)
End of
Lock-In Notice: Where Lock-In provisions are applicable, Enrollees must
be
notified sixty (60) days before the end of their Lock-In Period. The
SDOH or its
designee is responsible for notifying Enrollees of this provision in
applicable
LDSS jurisdictions.
D)
Notice
of Change to Guarantee Coverage: This notice will advise the Enrollee
that his
or her Medicaid or FHPlus eligibility is ending and how this affects
his or her
Enrollment in a MCO's MMC or FHPlus product. This notice contains pertinent
information regarding Guaranteed Eligibility benefits and dates of coverage.
If
an Enrollee is not eligible for Guarantee, this notice is not
necessary.
xvi)
The
LDSS may require that a MMC Enrollee that has been disenrolled at the
request of
the Contractor be returned to the Medicaid fee-for-service program. In
the
FHPlus program, a FHPlus Enrollee disenrolled at the request of the Contractor,
may choose another MCO offering a FHPlus product. If the FHPlus Enrollee
does
not choose, or there is not another MCO offering FHPlus in the LDSS
jurisdiction, the case will be closed.
APPENDIX
H
April
1,
2007
H-15
xvii)
In
those instances where the LDSS approves the Contractor's request to disenroll
an
Enrollee, and the Enrollee requests a fair hearing, the Enrollee will
remain
enrolled in the Contractor's MMC or FHPlus product until the disposition
of the
fair hearing if Aid to Continue is ordered by the New York State Office
of
Administrative Hearings.
xviii)
The LDSS is responsible for reviewing each Contractor-requested Disenrollment
in
accordance with the provisions of Section 8.7 of this Agreement and this
Appendix. Where applicable, the LDSS may consult with local mental health
and
substance abuse authorities in the district when making the determination
to
approve or disapprove the request.
xix)
The
LDSS is responsible for establishing procedures whereby the Contractor
refers
cases which are appropriate for an LDSS-initiated Disenrollment and submits
supporting documentation to the LDSS.
xx)
After
the LDSS receives and, if appropriate, approves the request for Disenrollment
either from the Enrollee or the Contractor, the LDSS is responsible for
updating
the PCP subsystem file with an end date. The Enrollee is removed from
the
Contractor's Roster.
b) Contractor
Responsibilities:
i)
In
those instances where the Contractor directly receives Disenrollment
forms, the
Contractor will forward these Disenrollments to the LDSS for processing
within
five (5) business days (or according to Section 6 of this Appendix).
During
pulldown week, these forms may be faxed to the LDSS with the hard copy
to
follow.
ii)
The
Contractor must accept and transmit all requests for voluntary Disenrollments
from its Enrollees to the LDSS, and shall not impose any barriers to
Disenrollment requests. The Contractor may require that a Disenrollment
request
be in writing, contain the signature of the Enrollee, and state the Enrollee's
correct Contractor or Medicaid identification number.
iii)
The
Contractor will make a good faith effort to identify cases which may
be
appropriate for an LDSS-initiated Disenrollment. Within five (5) business
days
of identifying such cases and following LDSS procedures, the Contractor
will, in
writing, refer cases which are appropriate for an LDSS-initiated Disenrollment
and will submit supporting documentation to the LDSS. This includes,
but is not
limited to, changes in status for its Enrollees that may impact eligibility
for
Enrollment such as address changes, incarceration, death, exclusion from
the MMC
program, the apparent enrollment of a member in the Contractor's MMC
or FHPlus
product under more than one CTN, etc.
APPENDIX
H
April
1,
2007
H-16
iv)
Pursuant to Section 8.7 of this Agreement, the Contractor may initiate
an
involuntary Disenrollment if the Enrollee engages in conduct or behavior
that
seriously impairs the Contractor's ability to furnish services to either
the
Enrollee or other Enrollees, provided that the Contractor has made and
documented reasonable efforts to resolve the problems presented by the
Enrollee.
v)
The
Contractor may not request Disenrollment because of an adverse change
in the
Enrollee's health status, or because of the Enrollee's utilization of
medical
services, diminished mental capacity, or uncooperative or disruptive
behavior
resulting from the Enrollee's special needs (except where continued Enrollment
in the Contractor's MMC or FHPlus product seriously impairs the Contractor's
ability to furnish services to either the Enrollee or other
Enrollees).
vi)
The
Contractor must make a reasonable effort to identify for the Enrollee,
both
verbally and in writing, those actions of the Enrollee that have interfered
with
the effective provision of covered services as well as explain what actions
or
procedures are acceptable.
vii)
The
Contractor shall give prior verbal and written notice to the Enrollee,
with a
copy to the LDSS, of its intent to request Disenrollment. The written
notice
shall advise the Enrollee that the request has been forwarded to the
LDSS for
review and approval. The written notice must include the mailing address
and
telephone number of the LDSS.
viii)
The
Contractor shall keep the LDSS informed of decisions related to all complaints
filed by an Enrollee as a result of, or subsequent to, the notice of
intent to
disenroll.
ix)
The
Contractor will not consider an Enrollee disenrolled without confirmation
from
the LDSS or the Roster (as described in Section 5 of this
Appendix).
APPENDIX
H
April
1,
2007
H-17
APPENDIX
L
Approved
Capitation Payment Rates
APPENDIX
L
April
1,
2007
L-l
WELLCARE
OF NEW YORK, INC.
Medicaid
Managed Care Rates
|
MMIS ID#: 01182503
|
Effective
Date: 04/01/07
|
|
Approved
by DOB: Yes
|
Region:
Northeast
|
|
Reinsurance: No
|
County: ALBANY
|
|
Premium
Group
|
Rate
Amount
|
|
TANF/SN <6mo
M/F
|
$266.66
|
|
TANF/SN 6mo-14 F
|
$90.84
|
|
TANF/SN 15-20 F
|
$132.88
|
|
TANF/SN 6mo-20 M
|
$88.65
|
|
TANF
21-64 M/F
|
$215.57
|
|
SN 21-29 M/F
|
$204.54
|
|
SN 30-64 M/F
|
$370.80
|
|
SSI
6mo-20 M/F
|
$179.30
|
|
SSI
21-64 M/F
|
$500.80
|
|
SSI
65+ M/F
|
$445.49
|
|
Maternity Kick Payment
|
$5,224.57
|
|
Newborn Kick Payment
|
$1,804.39
|
|
Optional Benefits Offered:
|
|
|
R
Emergency Transportation
|
£
Dental
|
|
R
Non-Emergent Transportation
|
R
Family Planning
|
Box
will
be checked if the optional benefit is covered by the plan
WELLCARE
OF NEW YORK, INC.
Medicaid
Managed Care Rates
|
MMIS ID#: 01182503
|
Effective
Date: 04/01/07
|
|
Approved
by DOB: Yes
|
Region: Central
|
|
Reinsurance: No
|
County: COLUMBIA
|
|
Premium
Group
|
Rate
Amount
|
|
TANF/SN <6mo
M/F
|
$259.46
|
|
TANF/SN 6mo-14 F
|
$85.50
|
|
TANF/SN 15-20 F
|
$143.93
|
|
TANF/SN 6mo-20 M
|
$85.89
|
|
TANF
21-64 M/F
|
$234.78
|
|
SN 21-29 M/F
|
$220.56
|
|
SN 30-64 M/F
|
$376.32
|
|
SSI
6mo-20 M/F
|
$183.98
|
|
SSI
21-64 M/F
|
$483.54
|
|
SSI
65+ M/F
|
$400.37
|
|
Maternity Kick Payment
|
$5,603.31
|
|
Newborn Kick Payment
|
$2,059.21
|
|
Optional Benefits Offered:
|
|
|
R
Emergency Transportation
|
£
Dental
|
|
R
Non-Emergent Transportation
|
R
Family Planning
|
Box
will
be checked if the optional benefit is covered by the plan
WELLCARE
OF NEW YORK, INC.
Medicaid
Managed Care Rates
|
MMIS ID#: 01182503
|
Effective
Date: 04/01/07
|
|
Approved
by DOB: Yes
|
Region:
Mid-Xxxxxx
|
|
Reinsurance: No
|
County: DUTCHESS
|
|
Premium
Group
|
Rate
Amount
|
|
TANF/SN <6mo
M/F
|
$272.19
|
|
TANF/SN 6mo-14 F
|
$96.26
|
|
TANF/SN 15-20 F
|
$139.03
|
|
TANF/SN 6mo-20 M
|
$105.93
|
|
TANF
21-64 M/F
|
$234.51
|
|
SN 21-29 M/F
|
$215.62
|
|
SN 30-64 M/F
|
$436.83
|
|
SSI
6mo-20 M/F
|
$181.04
|
|
SSI
21-64 M/F
|
$496.83
|
|
SSI
65+ M/F
|
$433.14
|
|
Maternity Kick Payment
|
$5,792.84
|
|
Newborn Kick Payment
|
$2,367.65
|
|
Optional Benefits Offered:
|
|
|
R
Emergency Transportation
|
£
Dental
|
|
£
Non-Emergent Transportation
|
R
Family Planning
|
Box
will
be checked if the optional benefit is covered by the plan
WELLCARE
OF NEW YORK, INC.
Medicaid
Managed Care Rates
|
MMIS ID#: 01182503
|
Effective
Date: 04/01/07
|
|
Approved
by DOB: Yes
|
Region: Central
|
|
Reinsurance: No
|
County: XXXXXX
|
|
Premium
Group
|
Rate
Amount
|
|
TANF/SN <6mo
M/F
|
$257.23
|
|
TANF/SN 6mo-14 F
|
$83.67
|
|
TANF/SN 15-20 F
|
$141.62
|
|
TANF/SN 6mo-20 M
|
$84.02
|
|
TANF
21-64 M/F
|
$231.91
|
|
SN 21-29 M/F
|
$217.76
|
|
SN 30-64 M/F
|
$373.21
|
|
SSI
6mo-20 M/F
|
$180.88
|
|
SSI
21-64 M/F
|
$479.49
|
|
SSI
65+ M/F
|
$398.65
|
|
Maternity Kick Payment
|
$5,603.31
|
|
Newborn Kick Payment
|
$2,059.21
|
|
Optional Benefits Offered:
|
|
|
R
Emergency Transportation
|
£
Dental
|
|
£
Non-Emergent Transportation
|
R
Family Planning
|
Box
will
be checked if the optional benefit is covered by the plan
WELLCARE
OF NEW YORK, INC.
Medicaid
Managed Care Rates
|
MMIS ID#: 01182503
|
Effective
Date: 04/01/07
|
|
Approved
by DOB: Yes
|
Region:
Mid-Xxxxxx
|
|
Reinsurance: No
|
County: ORANGE
|
|
Premium
Group
|
Rate
Amount
|
|
TANF/SN <6mo
M/F
|
$268.99
|
|
TANF/SN 6mo-14 F
|
$95.49
|
|
TANF/SN 15-20 F
|
$135.91
|
|
TANF/SN 6mo-20 M
|
$104.90
|
|
TANF
21-64 M/F
|
$231.09
|
|
SN 21-29 M/F
|
$211.14
|
|
SN 30-64 M/F
|
$430.70
|
|
SSI
6mo-20 M/F
|
$177.21
|
|
SSI
21-64 M/F
|
$488.48
|
|
SSI
65+ M/F
|
$428.29
|
|
Maternity Kick Payment
|
$5,792.84
|
|
Newborn Kick Payment
|
$2,367.65
|
|
Optional Benefits Offered:
|
|
|
£
Emergency Transportation
|
£
Dental
|
|
£
Non-Emergent Transportation
|
R
Family Planning
|
Box
will
be checked if the optional benefit is covered by the plan
WELLCARE
OF NEW YORK, INC.
Medicaid
Managed Care Rates
|
MMIS ID#: 01182503
|
Effective
Date: 04/01/07
|
|
Approved
by DOB: Yes
|
Region:
Northeast
|
|
Reinsurance: No
|
County: RENSSELAER
|
|
Premium
Group
|
Rate
Amount
|
|
TANF/SN <6mo
M/F
|
$264.44
|
|
TANF/SN 6mo-14 F
|
$89.01
|
|
TANF/SN 15-20 F
|
$130.59
|
|
TANF/SN 6mo-20 M
|
$86.79
|
|
TANF
21-64 M/F
|
$212.69
|
|
SN 21-29 M/F
|
$201.74
|
|
SN 30-64 M/F
|
$367.69
|
|
SSI
6mo-20 M/F
|
$176.21
|
|
SSI
21-64 M/F
|
$496.76
|
|
SSI
65+ M/F
|
$443.78
|
|
Maternity Kick Payment
|
$5,224.57
|
|
Newborn Kick Payment
|
$1,804.39
|
|
Optional Benefits Offered:
|
|
|
R
Emergency Transportation
|
£
Dental
|
|
£
Non-Emergent Transportation
|
R
Family Planning
|
Box
will
be checked if the optional benefit is covered by the plan
WELLCARE
OF NEW YORK, INC.
Medicaid
Managed Care Rates
|
MMIS ID#: 01182503
|
Effective
Date: 04/01/07
|
|
Approved
by DOB: Yes
|
Region:
Northeast Metro
|
|
Reinsurance: No
|
County: ROCKLAND
|
|
Premium
Group
|
Rate
Amount
|
|
TANF/SN <6mo
M/F
|
$251.68
|
|
TANF/SN 6mo-14 F
|
$89.59
|
|
TANF/SN 15-20 F
|
$113.90
|
|
TANF/SN 6mo-20 M
|
$100.10
|
|
TANF
21-64 M/F
|
$193.73
|
|
SN 21-29 M/F
|
$267.15
|
|
SN 30-64 M/F
|
$420.16
|
|
SSI
6mo-20 M/F
|
$179.66
|
|
SSI
21-64 M/F
|
$557.33
|
|
SSI
65+ M/F
|
$420.16
|
|
Maternity Kick Payment
|
$4,860.78
|
|
Newborn Kick Payment
|
$1,569.65
|
|
Optional Benefits Offered:
|
|
|
R
Emergency Transportation
|
£
Dental
|
|
£
Non-Emergent Transportation
|
R
Family Planning
|
Box
will
be checked if the optional benefit is covered by the plan
WELLCARE
OF NEW YORK, INC.
Medicaid
Managed Care Rates
|
MMIS ID#: 01182503
|
Effective
Date: 04/01/07
|
|
Approved
by DOB: Yes
|
Region:
Mid-Xxxxxx
|
|
Reinsurance: No
|
County: ULSTER
|
|
Premium
Group
|
Rate
Amount
|
|
TANF/SN <6mo
M/F
|
$268.99
|
|
TANF/SN 6mo-14 F
|
$95.49
|
|
TANF/SN 15-20 F
|
$135.91
|
|
TANF/SN 6mo-20 M
|
$104.90
|
|
TANF
21-64 M/F
|
$231.09
|
|
SN 21-29 M/F
|
$211.14
|
|
SN 30-64 M/F
|
$430.70
|
|
SSI
6mo-20 M/F
|
$177.21
|
|
SSI
21-64 M/F
|
$488.48
|
|
SSI
65+ M/F
|
$428.29
|
|
Maternity Kick Payment
|
$5,792.84
|
|
Newborn Kick Payment
|
$2,367.65
|
|
Optional Benefits Offered:
|
|
|
£
Emergency Transportation
|
£
Dental
|
|
£
Non-Emergent Transportation
|
R
Family Planning
|
Box
will
be checked if the optional benefit is covered by the plan
WELLCARE
OF NEW YORK, INC.
Family
Health Plus Rates Effective
April 1, 2007
|
Optional
benefits covered
|
||||||
|
County
|
Adults
with Children 19
- 64
|
Adults
without Children 19 - 29
|
Adults
without Children 30 - 64
|
Maternity
Kick
|
Family
Planning
|
Dental
|
|
ALBANY
|
$253.35
|
$250.47
|
$510.54
|
$5,224.57
|
Yes
|
Yes
|
|
COLUMBIA
|
$271.75
|
$259.93
|
$499.25
|
$5,603.31
|
Yes
|
Yes
|
|
DUTCHESS
|
$261.25
|
$292.21
|
$529.01
|
$5,792.84
|
Yes
|
Yes
|
|
XXXXXX
|
$271.75
|
$259.93
|
$499.25
|
$5,603.31
|
Yes
|
Yes
|
|
ORANGE
|
$261.25
|
$292.21
|
$529.01
|
$5,792.84
|
Yes
|
Yes
|
|
RENSSELAER
|
$253.35
|
$250.47
|
$510.54
|
$5,224.57
|
Yes
|
Yes
|
|
ROCKLAND
|
$257.02
|
$209.67
|
$472.63
|
$4,860.78
|
Yes
|
Yes
|
|
ULSTER
|
$261.25
|
$292.21
|
$529.01
|
$5,792.84
|
Yes
|
Yes
|
|
NEW
YORK CITY
|
$196.94
|
$151.51
|
$245.72
|
$5,523.56
|
Yes
|
Yes
|
